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New York State Department of Motor Vehicles DS-870 6/11 ARTICLE 19-A BUS DRIVER APPLICATION Complete all parts of this form. Please print or type. Send original to Bus Driver Unit keep a copy in your driver 19-A file. DRIVER INFORMATION Driver s Last Name First Street Address M. I. City State Client/License ID Number from Driver License Date of Birth Month/Day/Year Zip Code Social Security Number County Class of Driver s License Endorsements o Male o Female Telephone Number Restrictions Expiration Date CARRIER INFORMATION Carrier/DBA Name Legal Name if different Federal ID Number Name of Article 19-A Contact Person 19-A Business ID Number Title Is this employer/carrier a school bus carrier o Yes o No ADDITIONAL DRIVER INFORMATION Provide your employment accident and conviction history and answer the questions below. If necessary attach additional pages. 1. Have you qualified as a school bus driver under ARTICLE 19-A o Yes o No If yes give month and year of qualification 2. Are you a certified ARTICLE 19-A examiner o Yes o No If yes give certificate number and expiration date. EMPLOYMENT Start with your most recent employment and include work history for the past 3 years Employer Name and Address What were the date s of your employment From - To Your job title ACCIDENTS Start with your most recent accident and include accidents within the past 3 years Date of Accident Location City State Zip Code County Was there personal injury or property damage If YES indicate the dollar amount of damage to each vehicle and the number of people injured* What type of vehicle were you driving CONVICTIONS Start with your most recent conviction and include all criminal convictions Date of Violation Date of Conviction Of what charge were you convicted If a vehicle was involved what type of vehicle were you driving DRIVER AFFIRMATION To the best of my knowledge the information I have given on this application is true. - Signature of Driver Date EMPLOYER CERTIFICATION This application has been reviewed together with the driver abstract and medical examination form DS-874 or USDOT form 649-F or equivalent and the applicant is hereby classified as a conditional driver as defined in Section 6. 2 r and in accordance with the requirements of Sections 6. 3 and 6. 4 of the regulations of the Commissioner of Motor Vehicles. Final approval of employment is subject to the applicant meeting the requirements of Article 19-A of the New York State Vehicle and Traffic Law. All questions pertaining to this form and/or the Article 19-A Program should be directed to New York State Department of Motor Vehicles Bus Driver Unit 6 Empire State Plaza Rm 220C Albany NY 12228 518 473-9455. Send original to Bus Driver Unit keep a copy in your driver 19-A file. DRIVER INFORMATION Driver s Last Name First Street Address M. I. City State Client/License ID Number from Driver License Date of Birth Month/Day/Year Zip Code Social Security Number County Class of Driver s License Endorsements o Male o Female Telephone Number Restrictions Expiration Date CARRIER INFORMATION Carrier/DBA Name Legal Name if different Federal ID Number Name of Article 19-A Contact Person 19-A Business ID Number Title Is this employer/carrier a school bus carrier o Yes o No ADDITIONAL DRIVER INFORMATION Provide your employment accident and conviction history and answer the questions below.

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